CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1121 6994.75 256502.50 36.67
Subtotal (Total Children Is Unduplicated) 1121 6994.75 256502.50 36.67
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 17.00 183.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 25.00 544.75 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 54 73.00 5475.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 49.50 2747.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 67.00 5025.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 153.00 8483.25 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 220 282.00 21037.50 74.60
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 17.00 824.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 37 41.00 1988.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 21.00 1018.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 77 81.00 3881.00 47.91
Subtotal (Total Children Is Unduplicated) 464 944.00 58546.88 62.02
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 335 4204.00 210138.00 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 131 1136.15 77120.79 67.88
OCCT-97530HM-OT SESSION BY OT ASST 24 351.50 18876.20 53.70
PHY-97110-PT SESSION BY LICENSED PT 110 998.75 67795.15 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 16.00 869.12 54.32
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 199 1515.75 102821.23 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
Subtotal (Total Children Is Unduplicated) 542 8243.65 478361.05 58.03
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Total 16182.40 793410.43 49.03
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Number of Children (Unduplicated) With at Least One Service 1133
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Center 54
Flag Claims Units Chgs Paid
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R 17 11.25 407.00 0.00
U 0 0.00 0.00 0.00
B 4077 2717.00 102439.23 0.00
P 7188 4812.50 188718.75 225924.11
D 11 8.25 318.25 0.00
S 1 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4152 8632.65 501499.45 0.00
Other 0 0.00 0.00 0.00
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Total 15446 16182.40 793410.43 225924.11